EMR Design - Data Type Combinations
Posted Saturday, October 18, 2008 by Betsy Haines

I promised in my last blog to provide examples of capturing EMR information in artful and disciplined combinations of narratives and of clickable lists and scales. For me artful and disciplined means the essential information, not more and not less, is presented in formats that best capture its significance and that best serve the therapeutic effort.  But first a disclaimer: I have thought long and hard, alone and with others about these issues. I aspire to this “artful and disciplined” standard, but I have probably misled you about having achieved it. Anyway, here goes…

 

(NOTE: You can view screen shots of these examples in this document. The document also includes more discussion of the thinking and decision points leading to the final design.)



 

The patient has sought help because of a complex mix of events, feelings and behaviors. There is a story that must be told, heard and conveyed into your EMR. Only a narrative can convey the chronologies, emotions, conflicts and relationships involved. Traditional wisdom calls for the Chief Complaint/Presenting Problem to be captured in the person’s own words and the surrounding story (History of Present Illness) to be presented in narrative form. Depending on the treatment context, the narrative story-line can be continued through the past treatment, developmental and personal histories.  



 

Of course, there are numerous elements embedded in the client's story. Many are interesting and relevant; but discipline requires that only those few that are important because of their risk, their impact, or their prognostic value be captured in structured formats. (In some settings, items are also included in reportable formats because of their potential relevance to research and outcome activities. Also most settings must collect certain information for administrative purposes.) For example, suicidal thoughts and behavior clearly meet this threshold. Dictionary based data fields can highlight the presence of suicidal risk, then help identify contributing and mitigating factors and finally communicate the assessed extent of risk. The attached document shows details. Other areas warranting abstraction from the story might include psychiatric hospitalizations, substance abuse, arrests, medical problems, family history of mental illness and so forth.

 

After having captured and selectively abstracted the story of the client’s problems, the clinician must synthesize the material into a clinical formulation. This integrative process needs narrative to fully portray its content. Then typically, the clinician must specify areas on which to focus the therapeutic work and identify facilitating and obstructing factors. These last are readily and usefully done with lists. Again the attached document shows details of such an effort.

 

As you can see, this is not rocket science. My point is that narratives and lists and scales are complementary. 
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EMR Design - to Type or to Click
Posted Saturday, October 18, 2008 by Betsy Haines

Now that I have just advocated for EMR content customization, let’s return to content design. This is my favorite part of EMR implementation. I wrote earlier on educating the clinician members of your design team about databases. Next they need to understand the different data types available for capturing information and the implications of data type decisions. 

The most important distinction is between free text and dictionary-based data types. Everyone is already familiar with the notion of typing ongoing text. Similarly, most people have encountered check boxes on forms, e.g. medical histories attached to clipboards in doctor waiting rooms. Clinicians are comfortable with creating narratives as part of clinical histories and other documentation. Indeed I have seen several behavioral health EHR’s that consist entirely of textboxes for entering the organizations’ usual narrative content. Such EMR’s are essentially electronic paper, but what a waste! Among the advantages of an EMR are efficiency, standardization and aggregated reporting.  None of these is achieved using narrative textboxes.

 

But deeper issues lie beneath the type or click choice. Clinicians think of the clinical history as the patient’s story. I heartily agree with this. Effective treatment is grounded in understanding the story of the person’s problems and suffering. At the same time, the story includes numerous individual pieces of information, for example, past substance abuse, the presence of a firearm in the house, sexual abuse by a family member rather than a stranger and a parent who committed suicide. Such salient features of client stories, alone or in combination, can serve to trigger alerts about individual risk. They can help supervisors and administrators identify and monitor the care of clients with a defined set of problems. Aggregated, they can guide managers to unmet service needs.

 

Likewise, a case summary can be a text formulation and/or lists and measurement scales. The former presses the clinician to integrate an explanatory narrative that justifies an approach to treatment. The latter asks the clinician to abstract specific problems and strengths, to assign a diagnosis and to quantify patient attributes in various domains. The narrative facilitates reflection and understanding. The lists and scales sharpen focus and enable accountability. Aggregated lists and scales can help address important questions including about outcomes, efficacy and best use of resources.

 

Likewise with progress notes and so on. Now what of the original question – to type or to click? The answer is to do both in artful, disciplined combinations. In my next blog, I’ll give some examples of such combinations, which I hope will be artful and disciplined or at least useful. 

 

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Mental Health Services Improvement Act (H.R. 5176/S. 2182)
Posted Tuesday, June 24, 2008 by Kevin Scalia
Supporting NCCBH in Washington

Last week I attended the NCCBH Hill day in Washington, D.C. to lobby on Capitol Hill for legislation that supports the mental health community.  We addressed many issues effecting the industry (a list of the agenda we addressed can be found at the National Council for Community Mental Health website), but I particularly focused on one that effects the users of our Electronic Medical Record systems:  The Support the Community Mental Health Services Act (H.R 5176/S. 2182).  

This act addresses the need to provide funding to co-locate primary care/chronic care services at CMHCs; to integrate treatment for co-occuring mental heath and substance abuse disorders; to provide funding for workforce recritment and retention; to enhance behavioral health eduction and training; to provide funding for telepsychiatry and patient education; and finally one that directly impact users of electronic health records, psychiatric software, and medication management systems.  This final measure would require the Secretary of HHS to collaborate with the Office of the national coordinator to develop a plan to ensure that components of the National Health Information Infrastructure address the needs of behavioral and substance abuse providers.  

I met with Senator Hilary Clinton, Senator Charles Schumer and Congressman Steve Israel and got very good response from all offices.  We requested that they co-sponsor the legislation and endorse it.  I recommend that each of you communicate with your local legislators and request the same.  It is easier than you think.   

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External Connected Care
Posted Friday, May 9, 2008 by Kevin Scalia
External Connected Care

In my last blog entry I discussed Internal connected care.  To truly have connected care, internal connected care is the enabling technology to facilitate external connected care.  External connected care is the ability to share clinical data between disparate providers.  It allows a discharge summary to arrive at another provider before the consumer arrives to give the agency the consumer's diagnosis, active medications, reason for referral, demographic data and much more.  We call this new product CareConnect, and are using the evolving national standard called a Continuity of Care Document (CCD) transfer information between Avatar, MIS and Insight systems.  

Many behavioral health and public health agencies do not have the resources to Develop and maintain interfaces to various RHIOs and other providers.  The Netsmart CareConnect system will allow them to make a single connection to CareConnect and have Netsmart manage the interfaces to other providers and RHIOs.  Connecting care in this fashion will provide better service to the consumer by reducting potential medication errors and by reducing inpatient admissions by emergency rooms by providing the clinicians with the information they need when they need it.

We are continuing to define and extend the CCD to add behavioral and public health extensions.  At Connections a few weeks ago we had some discussions about these extensions.  Some preliminary ideas were to add components of a substance abuse assessment, a risk assessment and a suicide assessment.  What are your thoughts?
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